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Meta-Analysis
. 2012 Dec 12;12(12):CD007787.
doi: 10.1002/14651858.CD007787.pub2.

Drugs for treating giardiasis

Carlos E Granados  1 , Ludovic Reveiz, Luis G Uribe, Claudia P Criollo
Affiliations
Meta-Analysis

Drugs for treating giardiasis

Carlos E Granados et al. Cochrane Database Syst Rev. .

Abstract

Background: Giardiasis infection may be asymptomatic, or can cause diarrhoea (sometimes severe), weight loss, malabsorption, and, in children, failure to thrive. It is usually treated with metronidazole given three times daily for five to 10 days.

Objectives: To evaluate the relative effectiveness of alternative antibiotic regimens for treating adults or children with symptomatic giardiasis.

Search methods: We searched the Cochrane Infectious Disease Group Specialized Register, the Cochrane Central Register of Controlled Trials (CENTRAL) (Issue 6 2012); MEDLINE, EMBASE, LILACS and the International Clinical Trials Registry Platform Search Portal (3 July 2012).

Selection criteria: We included randomized controlled trials (RCT) comparing metronidazole administered for five to 10 days with any of the following drugs: metronidazole (single dose), tinidazole, albendazole, mebendazole, and nitazoxanide. The primary outcomes were parasitological and clinical cure.

Data collection and analysis: Two authors independently assessed studies for inclusion, performed the risk of bias assessment, and extracted data. We summarized data using risk ratios and mean differences and we presented the results in forest plots and performed meta-analyses where possible. We assessed heterogeneity using the Chi(2) test, I(2) statistic and visual inspection; and we explored this by using subgroup analyses.We assessed the quality of evidence by using the GRADE approach.

Main results: We included 19 trials, involving 1817 participants, of which 1441 were children. Studies were generally small, with poor methods reporting. . Most reported parasitological outcomes rather than clinical improvement.Ten trials, from India, Mexico, Peru, Iran, Cuba, and Turkey, compared albendazole (400 mg once daily for five to 10 days) with metronidazole (250 mg to 500 mg three times daily for five to 10 days). This once-daily regimen of albendazole is probably equivalent to metronidazole at achieving parasitological cure (RR 0.99, 95% CI 0.95 to 1.03; 932 participants, 10 trials; moderate quality evidence), and improving symptoms (RR 0.98, 95% confidence interval (CI) 0.93 to 1.04; 483 participants, five trials; moderate quality evidence), but the duration of follow-up was short (two to three weeks). Albendazole probably has fewer side effects than metronidazole (gastrointestinal side effects: RR 0.29, 95% CI 0.13 to 0.63; 717 participants, eight trials; moderate quality evidence; neurological side effects: RR 0.34, 95% CI 0.18 to 0.64; 453 participants, five trials; low quality evidence).Five trials from Turkey, Spain and the UK compared mebendazole (200 mg three times daily for five to 10 days) with metronidazole (5 mg/kg (or 250 mg) three times daily for five to 10 days). These trials were small in size, and at high risk of bias. Consequently, reliable conclusions on the relative effectiveness cannot be made (very low quality evidence).Five further trials, from Iran, Spain and Peru, have evaluated shortened regimens of tinidazole (single dose; 179 participants, three trials), metronidazole (single dose; 55 participants, one trial), and nitazoxanide (three days; 55 participants, one trial). Again, these trials were at high risk of bias and too small to reliably detect or exclude important differences (very low quality evidence).

Authors' conclusions: Albendazole may be of similar effectiveness to metronidazole, may have fewer side effects, and has the advantage of a simplified regimen. Large, high quality trials, assessing clinical outcomes (such as diarrhoea) will help assess further alternatives.

PubMed Disclaimer

Conflict of interest statement

None known.

Figures

1
1
Study flow diagram.
2
2
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
3
3
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
1.1
1.1. Analysis
Comparison 1 Albendazole (once daily) versus metronidazole (three times daily), Outcome 1 Parasitological cure (at 1 to 3 weeks).
1.2
1.2. Analysis
Comparison 1 Albendazole (once daily) versus metronidazole (three times daily), Outcome 2 Time to achieve parasitological cure (hours).
1.3
1.3. Analysis
Comparison 1 Albendazole (once daily) versus metronidazole (three times daily), Outcome 3 Clinical improvement (at 2 to 3 weeks).
1.4
1.4. Analysis
Comparison 1 Albendazole (once daily) versus metronidazole (three times daily), Outcome 4 Time of symptomatic improvement (hours).
1.5
1.5. Analysis
Comparison 1 Albendazole (once daily) versus metronidazole (three times daily), Outcome 5 Other adverse events (gastrointestinal at 1 to 3 weeks).
1.6
1.6. Analysis
Comparison 1 Albendazole (once daily) versus metronidazole (three times daily), Outcome 6 Other adverse events (neurological at 1 to 3 weeks).
1.7
1.7. Analysis
Comparison 1 Albendazole (once daily) versus metronidazole (three times daily), Outcome 7 Other adverse events (metallic taste at 3 weeks).
1.8
1.8. Analysis
Comparison 1 Albendazole (once daily) versus metronidazole (three times daily), Outcome 8 Other adverse events (allergic/cutaneous at 3 weeks).
1.9
1.9. Analysis
Comparison 1 Albendazole (once daily) versus metronidazole (three times daily), Outcome 9 Other adverse events (fever at 3 weeks).
1.10
1.10. Analysis
Comparison 1 Albendazole (once daily) versus metronidazole (three times daily), Outcome 10 Other adverse events (transient elevation of liver enzymes at 3 weeks).
1.11
1.11. Analysis
Comparison 1 Albendazole (once daily) versus metronidazole (three times daily), Outcome 11 Other adverse (transient neutropenia at 3 weeks).
1.12
1.12. Analysis
Comparison 1 Albendazole (once daily) versus metronidazole (three times daily), Outcome 12 Non‐compliance to treatment (at 2 weeks).
2.1
2.1. Analysis
Comparison 2 Mebendazole (three times daily) versus metronidazole (three times daily), Outcome 1 Parasitological cure (at 1 to 2 weeks).
2.2
2.2. Analysis
Comparison 2 Mebendazole (three times daily) versus metronidazole (three times daily), Outcome 2 Other adverse events (nausea/vomiting at 1 to 2 weeks).
2.3
2.3. Analysis
Comparison 2 Mebendazole (three times daily) versus metronidazole (three times daily), Outcome 3 Other adverse events (headache at 1 to 2 weeks).
2.4
2.4. Analysis
Comparison 2 Mebendazole (three times daily) versus metronidazole (three times daily), Outcome 4 Other adverse events (urticaria at 1 to 2 weeks).
3.1
3.1. Analysis
Comparison 3 Tinidazole (single dose) versus metronidazole (three times daily), Outcome 1 Parasitological cure (at 3 weeks to 1 month).
3.2
3.2. Analysis
Comparison 3 Tinidazole (single dose) versus metronidazole (three times daily), Outcome 2 Clinical improvement (at 3 weeks to 1 month).
3.3
3.3. Analysis
Comparison 3 Tinidazole (single dose) versus metronidazole (three times daily), Outcome 3 Other adverse events (gastrointestinal at 3 weeks to 1 month).
3.4
3.4. Analysis
Comparison 3 Tinidazole (single dose) versus metronidazole (three times daily), Outcome 4 Other adverse events (neurological at 3 weeks to 1 month).
3.5
3.5. Analysis
Comparison 3 Tinidazole (single dose) versus metronidazole (three times daily), Outcome 5 Other adverse events (allergic/cutaneous at 3 weeks to 1 month).
3.6
3.6. Analysis
Comparison 3 Tinidazole (single dose) versus metronidazole (three times daily), Outcome 6 Other adverse events (fever at 3 weeks to 1 month).
3.7
3.7. Analysis
Comparison 3 Tinidazole (single dose) versus metronidazole (three times daily), Outcome 7 Serious adverse events (at 3 weeks to 1 month).
4.1
4.1. Analysis
Comparison 4 Metronidazole (single dose) versus metronidazole (three times daily), Outcome 1 Parasitological cure (at 2 weeks).
4.2
4.2. Analysis
Comparison 4 Metronidazole (single dose) versus metronidazole (three times daily), Outcome 2 Other adverse events (gastrointestinal at 2 weeks).
4.3
4.3. Analysis
Comparison 4 Metronidazole (single dose) versus metronidazole (three times daily), Outcome 3 Serious adverse events (at 2 weeks).
5.1
5.1. Analysis
Comparison 5 Nitazoxanide (twice daily) versus metronidazole (twice daily), Outcome 1 Parasitological cure (at 1 week).
5.2
5.2. Analysis
Comparison 5 Nitazoxanide (twice daily) versus metronidazole (twice daily), Outcome 2 Reduction in symptoms of diarrhea (at 1 week).
5.3
5.3. Analysis
Comparison 5 Nitazoxanide (twice daily) versus metronidazole (twice daily), Outcome 3 Other adverse events (at 1 week).
5.4
5.4. Analysis
Comparison 5 Nitazoxanide (twice daily) versus metronidazole (twice daily), Outcome 4 Other adverse events (abdominal pain at 1 week).
5.5
5.5. Analysis
Comparison 5 Nitazoxanide (twice daily) versus metronidazole (twice daily), Outcome 5 Other adverse events (nausea/vomiting at 1 week).
5.6
5.6. Analysis
Comparison 5 Nitazoxanide (twice daily) versus metronidazole (twice daily), Outcome 6 Other adverse events (headache at 1 week).
See this image and copyright information in PMC

Update of

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